Hindawi Publishing Corporation Case Reports in Dermatological Medicine Volume 2013, Article ID 381583, 3 pages http://dx.doi.org/10.1155/2013/381583

Case Report Simultaneous Larva Migrans and Larva Currens Caused by Strongyloides stercoralis: A Case Report

Liliam Dalla Corte, Mariana Vale Scribel da Silva, and Paulo Ricardo Martins Souza

Santa Casa de MisericordiadePortoAlegre,PortoAlegre,RS,Brazil´

Correspondence should be addressed to Liliam Dalla Corte; [email protected]

Received 21 November 2012; Accepted 14 January 2013

Academic Editors: S. Inui and S. Kawara

Copyright © 2013 Liliam Dalla Corte et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Strongyloidiasis is an infectious disease caused by the Strongyloides stercoralis larvae, which penetrate the skin, go through the lymphatic circulation, and migrate to the before reaching the intestines. They mature and may cause cutaneous strongyloidiasis, known as larva currens because of the quick migratory rate of the larva. The authors describe a case in which the larvae did not follow their natural lymph route, and after penetrating into the intertriginous area, they migrated to the dermis, developing larva migrans in the early phase, and later associated with the typical lesions of larva currens. The diagnosis was confirmed by the presence of larva in the skin biopsy.

1. Introduction reached his left thigh (Figures 2 and 3). Progressively, some new urticarial, linear lesions appeared in his trunk. He denied Strongyloides stercoralis is especially endemic in many trop- using any medications and did not report any signs or ical countries, where it has become a matter of concern symptoms. in the public health area [1–7]. The special characteristic There were no changes in the blood, stool, and partial features of its life cycle are chronicity, autoinfection, and easy parasitological urine tests, except for the in dissemination. It is a difficult to diagnose as the blood test. The initial diagnosis was vasculitis due to itrequiresthedirectvisualizationofthelarvae[1]. the purpuric lesions; however, with the emergence of some The infection is asymptomatic in most cases; however, the lesionsinthetrunk,therewasthechancethatitcouldbelarva pathognomonic skin lesion of chronic strongyloidiasis is the currens. A systemic, empirical treatment was carried out with larva currens [2, 3]. Its diagnosis may be difficult to obtain (200 mcg/kg/day) for 3 consecutive days. The skin duetoatypicalmanifestations[3]. lesions and the eosinophilia regressed. Later, the pathology In this study, we described a rarely observed case of showed the larvae in the epidermis (Figures 4, 5,and6). simultaneous larva migrans and larva currens caused by Strongyloides stercoralis. 3. Discussion 2. Case Report Thisisapatientwitharareandanatypicalcutaneousstrongy- loidiasis, which was confirmed by the presence of larvae in A healthy 36-year-old white man from the city of Porto the skin biopsy. The most common form of transmission Alegre, RS, Brazil, was fishing barefoot near a pond and of Strongyloides stercoralis is through the skin, primarily after a period of 24 hours developed some cutaneous through the feet of people who do not wear any type of shoes hemorrhagic blisters on his left foot (Figure 1). In 3 days, [1–3]. The main skin changes occurred due to mechanical, such condition evolved into pruritic, linear to serpiginous, traumatic, toxic, irritant, and antigenic actions from females, erythematous urticarial lesions in the left lower limb and larvae, and eggs [3, 4]. 2 Case Reports in Dermatological Medicine

Figure 1: Area larvae penetration. Hemorrhagic blisters in the area: Figure 4: Larva currens. Erythematous, edematous urticarial the larvae penetrated the skin and the purpuric serpiginous lesions lesions in the back and the abdomen. in the back of the left foot.

Figure 2: Larva migrans. Diffuse purpuric lesions showing the Figure 5: Pathology. PAS 10x: presence of larva PAS positive in various routes the larvae took in the left thigh. stratum corneum.

Figure 3: Biopsy site in the popliteal region. Figure 6: Strongyloides stercoralis. Presence of larva in the corneal layer.

After penetrating the dermis, the larvae reach the blood circulation. These larvae may not find their natural route [3, 4, 6]. Sometimes, a single or multiple migration of and remain in the integument, thus exhibiting a rarely Filaroides larvae is observed in the subcutaneous tissue, observedconditionoflineardermatitisoflarvamigrans resulting in a pruritic, linear to serpiginous, erythematous caused by Strongyloides stercoralis [5, 6]. urticarial lesion characterized as larva currens, more com- There is some light skin reaction in the site where the monly found in the trunk, buttocks, perineum, groin, and penetration of the infective larvae occurred. On reinjec- thighs, moving at a rate of 5–15 cm/h [5]. tion, there is a hypersensitivity reaction that causes edema, The clinical diagnosis is difficult, considering that approx- erythema, itching, and hemorrhagic and urticarial papules imately 50% of cases present no symptoms. The presence Case Reports in Dermatological Medicine 3 of , abdominal , and urticaria is suggestive. Eosinophilia and serological and radiological findings can be helpful [5]. The parasitological methods or direct examination is based on the combination of the Strongyloides stercoralis evolutionary forms [1, 2, 5, 6]. Treatment of strongyloidiasis caused by larvae can be very difficult. The drugs of choice are thiabendazole 50 mg/kg twice daily for 2 to 3 days, 400 mg once daily for 3 days, and ivermectin 200 mcg/kg single oral dose [7]. This is a case of simultaneous larva migrans in the lower limbsandlarvacurrensintheabdomenandtheback, evidencing the change of direction taken by the larva, which was proven by the occurrence of Strongyloides stercoralis in theskinbiopsy.Theearlydiagnosisallowedanimmediateand appropriate therapeutic treatment to avoid greater morbidity.

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[1] P. D. Neves, L. A. Melo, M. P. Linardi, and A. W. R. Vitor, Parasitologia Humana, Atheneu, 11th edition, 2005. [2] A. V. Neto, S. L. J. Baldy, C. M. Ramos, and N. L. M. Branchini, Parasitoses Intestinais, Sarvier, 3rd edition, 1989. [3]M.N.Ly,S.L.Bethel,A.S.Usmani,andD.R.Lambert, “Cutaneous Strongyloides stercoralis infection: an unusual presentation,” Journal of the American Academy of Dermatology, vol. 49, supplement 2, pp. S157–S160, 2003. [4] B. Gaus, F. Toberer, A. Kapaun, and M. Hartmann, “Chronic strongyloides stercoralis infection. Larva currens as skin mani- festation,” Hautarzt,vol.62,no.5,pp.380–383,2011. [5]M.Corti,M.F.Villafane,˜ N. Trione, D. Risso, J. C. Abu´ın, and O. Palmieri, “Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients,” Revista Chilena de Infectologia,vol.28,no.3,pp.217– 222, 2011. [6] L. X. Liu and P. F. Weller, “Strongyloidiasis and other intestinal nematode infections,” Infectious Disease Clinics of North Amer- ica,vol.7,no.3,pp.655–682,1993. [7] Y. Suputtamongkol, N. Premasathian, K. Bhumimuang et al., “Efficacy and safety of single and double doses of ivermectin versus 7-day high dose albendazole for chronic strongyloidia- sis,” PLoS Neglected Tropical Diseases,vol.5,no.5,ArticleID e1044, 2011. M EDIATORSof INFLAMMATION

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